SAGE DI CLINICAL ROTATION CHECKLIST

For your clinical rotation, the curriculum provides supervised practice and didactic learning activities to support supervised practice for various conditions, including but not limited to overweight and obesity, diabetes, cancer, cardiovascular, gastrointestinal and renal diseases.

DIRECTIONS: Please print off hard copy and complete the following form four times during your clinical rotation: at mid-point and at the end of your MNT rotation and at the end of DM, Renal and/or other outpatient rotations. This is meant to assess your progress throughout your rotation. This form should be completed ONCE ONLINE at the end of your clinical practicum.

NOTE: The online forms cannot be saved or edited after submission. If you would like a copy emailed to you, please contact mccomk@sage.edu.

Intern Name
FirstLast

Select Internship Track

Rotation
*

Facility
*

Preceptor Name
*

Date Rotation Began
*

Date Rotation Ended
*

1. NUTRITION ASSESSMENT
How often were you exposed to Nutrition Assessment?

2. NUTRITION DIAGNOSIS
How often were you exposed to Nutrition Diagnosis

3. NUTRITION INTERVENTION
How often were you exposed to Nutrition Intervention

4. NUTRITION PRESCRIPTION
How often were you exposed to Nutrition Prescription

5. NUTRITION MONITORING & EVALUATION
How often were you exposed to Nutrition Monitoring and Evaluation

6. WEIGHT MANAGEMENT AND OBESITY
How often were you exposed to Weight Management and Obesity

7. DIABETES MELLITUS
How often were you exposed to Diabetes Mellitus

8. CANCER
How often were you exposed to Cancer

9. CARDIOVASCULAR DISEASE
How often were you exposed to Cardiovascular Disease

10. GASTROINTESTINAL DISORDERS
How often were you exposed to Gastrointestinal Disorders

11. RENAL DISEASE
How often were you exposed to Renal Disease

12. TUBE FEEDING
How often were you exposed to Tube Feeding

13. TOTAL PARENTERAL NUTRITION (TPN)
How often were you exposed to TPN

14. CHILDREN/PEDIATRICS
How often were you exposed to Children/Pediatrics